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04476
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04476
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CONSTRUCTION
Located at
Subdivision
PUTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER TO PROVIDE PERMIT #
ON CERT F I C E OF POMP.I ANA
Division of Environmental Health Services, Carmel, N. Y. 10512 PERMIT
.SF-IAIAGE, DISPOSAL SYSTEM
14)/�� I own or Village
fed, 1 — Tax Map Biook .lut. _ ....... -
Subd. Lot a
Owner /Address �" iw • _
Lot Area
Building Type
Number of Bedrooms Design Flow G /P /D
____L__ --
Separate Sewerage System to consist Of Gal. Septic Tank
To be constructed by
Renewal ❑ Revision _❑
Date Of Previous Approval Fill Section Only ❑
P.C. H. Notification Requiredy.�
and U �� .�i7 f� i✓1G° �P1�1?�sf
Address
Water Supply: Public Supply From L
---4-'Private Supply to be drilled by
Address
Other Requirements eeeaoacenoonn
yo E @ the separate sewage disposal system
1 represent that I am wholly and completely responsible for the design and location of the propot�(5 ►, 11 r s an regulations O e u nam
above described will be constructed as shown on the approved amendment there to and in actor A (+ "pew t� t r o the Commissioner of Healthwill
County Department of Health, and that on completion thereof a "Certificate of Constructs C 4fb irs orb s b°the builtler, that said builder will
be submitted to the Department, and a written guarantee will be furnished the owner, hi suds, ears i ly following the date of the isw-
place in good operating condition any part of said sewage disposal system during the p �d wo (. eto 2 thhaa the drilled well described above
ante of the approval of the Certificate of. Construction Compliance of the original syst or' ' say r b�P
will be located as shown on the approved plan and that said well will be installed in accordan wh the ' s, r anal regula ons of the Putnam
County Department of Health.
P.E.
Date ign d ee 4 ..--
r
Address
he building has been undertaken and is
APPROVED FOR CONSTRUCTION: This proval expires one year from the date issued u ss c
revocable for cause or may be amended o modified when idered necessary by the Co issioner f Health. Any Chan or n of construction
require4new rmit Appr r disposal of dome is ita sew a or priv to wata p Y
Title
Date
BY
Rev. 6/85 ._ _:AA IT. - "
All � PUTNAM COUNTY DEPARTM ENT ••) OF HEALTH ENGINEER MUST
Division of Environmental Health 5ervroes, Carmel, N. Y. 10512 pERMITE#
"CMIF1C " OF CONSTRUCTIONV- COMPLIANCE -FOR SEWAGE 'DISPOSAL SYSTEM I)r-> "I e
Town or Village
Located at d ✓?
�L/ ,LY ,J� Tax Map Block
Owner r �i / 13 ref'./ %l4/• Cam/ Formerly Tax Map Lot # ,=J (
1- Subd. Lot If
Separate Sewerage System built by & kv-tn t' P
.cr /fir Address
Consisting of Gal. Septic Tank and
Other r �®
equirements
Water Supply: Public Supply From ✓�� / ✓1 i`r+ 0✓Jr
Private Supply Drilled By
Address
Building Type No, of Bedrooms 7
Date Permit issued
Has Erosion Control Been Completed? Has garbage grinder been installed?
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulations, in accordance with the
Putnam County Department Of filed plan, and the permit issued by the
Healltth.
%l G of E
Date
Cer ttf led by
=e . P.E. R.A.
Address
License No.
Any person occupying premises served by the bove system(s) shall pro tly s h°ecti
conditions resulting from such usage. Approval of the se a ass 'to secure the correction of any unsanitary
available and t e a prvate sewer ge sy nr al s and 'loon as a public sanitary sewer becomes
pprovsi f the private water supply shall become null nd a ter
subJect to mo ificati n di change when, in the Judgment of the Com Issi a becomes available. : `Such approvals are
i ► N cation or change is, necessary.
Date
By a
Title —��
PUTNAM COUNT( DEPARTMENT OF HEALTH
DIVISION OF ENVIROi�TAL HEALTH SERVICES
... .,_,
I
er or Purchaser of Building
Building Constructe/d. by
Location -'Street,
Municipality
Building Type
Section Block
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEMM DISPOSAL SYSTEM
I represent that I am-wholly and completely responsible for the location,
workmanship, 'material ; construction and drainage of the sewage disposal system
serving the 'above described property, and that it has been constructed as shown on
the approved plan or'approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years immediately following the date of approval of the
w
"Certificate.-of Construction .Compliance" for the sewage disposal system, or any
repairs miade 6y me to'.such, system, except= where the failure-to opezacte pxoperly °Rzs
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent. act of the occupant of the building utilizing
the system.
Dated this day of 19 (F'd
1
,Abn&al Contractor (Owner) - Signature
(',yuCX�c
� y '
u
rporation Name (if Cog.)
6e P,
3
Rr_�
rev. 9/85
mk
Signature
Title
rat: o_,Name (Y �Cor . )
Add ess T�
s
FIM-CF-T �* YI• a �� • � , .- ,� ♦/ �� Ya •� a INS
FIEND +IRfiSPDLT�ON RED .
DATE:
INSP. BY:
(Name of.Owner) (Street Location)
INITIAL SITE INSPECTION YES NO CPI'S
Wetlands on/or proximate to property ..............
Property lines or corners found ...................
Can estimate house location ........................
Will driveway need cut .:....................:.....
Must trees be removed - note these................
Deep holes representative of entire SDS area......
Additional deep holes needed............ w
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells/ septics ......................... ..
D.H. 1 Lot
Depth to G.W.
Depth to rock
Soil Descriptii
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
D.H. 2 Lot
Depth to G.W.
Depth to rock
Soil Descri tia
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 Lot
Depth to G.W.
Depth to rock
Soil
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
DATE:
FINAL SITE INSPECTION INSP . BY • YES NO COMMENTS
House SSDS located per approved plan .............
Length of trench measured 4GY�
Width of trench average
Slope of tile line and trench acceptable.........
Roan allowed for expansion trenches.. `
............
Over 100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded .............................
10 ft. maintained from property line and
20 ft. from house........... ���c ......... �%
Distance well to SSDS (ft.).. ... mil/.........
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench................
15 ft. of peripheral soil horizontally
from trench ..... ...............................
Boxes properly set .............................••
Could surface runoff from driveway, roads,
ground surface, etc., channel near SDS area...,
Does lot drainage appear OK in area of SDS.......'
is Std, Rem'rl<3
0
Dill LRJ71 ITS
Yes-
DIo
= .Conmonts
Property lines or corners found . . . . .
Can estimate house location . . . . . . . .
�Q
ARP L6CAr10N .
P
)use plans O.K.
Am _
% Q
:sign data sheet ✓
s
,res presoaked?
+ �-
in. 30" perc test depth
-
�nst. results for 3 runs i
NON FW W
Hole lots 0. K. �
1
)rporate Affidavit for other than individual
Additional doep holes needed. . . . . . , p .
�.i
ithorization for engineer
I
Sufficient SITS area available considering
,tter from Water Supply if applicable
'
I
!
variance requested -such noted on plans & apps.:
-_
r E ' Fvrj SbN E
161JRT%1RE � --"L 0"3 P�q
NAILS I, J.
Depth: # - - --
- DepTM I PRea- SHOl.:n ( Cy) NOr--: PIAM r0 BF VROJ,4ED
dst}ng contours shown (show new contours) a
.opes for driveway cuts, etc. shoran
Water elevation:. _
Lter service line location
Loting drain, etc. location + ✓
I
)p slope, bottom slope of fill I
+
:rcolation tests and deep test pit location I
a 1=
:Dtic tank size and conformance to std. ✓ +
I
13. R. house minimum
!
Luse setback shown
.stribution box ft,. belcnr frost ✓
i
.1 water within ;�t. of..PL shown -• .:
.-'.L-,Ch
SNG 12" j)ZOVE 6eapc G
` rJ� Wc; LV_ . ✓f
11....
Plan and profile SDS .. ...� ........
....... ...... ;
f
All other wells and SDS closer 2001 + I
shown or reference made
_..._
Property boundaries (metes and bounds- clearly shown)
Width of trench average
Slope of tile line and tr— encFi.acceptable .
LEGRL sL,aolus+°,.� i J
� -�
�fISTINCa Appeov4L ,
_..
REALTY vV�DNIS10rJ Z.
_•.
Natural soil not-.stripped or SDS area
WerLAAJb tD MI S
..
i'ARPMON DISTANCFS SPECIFIED ON PL4N
'
1
to P.L. gy
', to foundation wa lls
to Nearest well ! w +c
Y to stream, march, lake, etc. incl.expans on —
' to Curtain drain R
_
' to water line (pits -20
' to storm drain !
'*to large trees
' from foundation to septic tan:
' to pipe from leader drain &,fooUne, drain.
i To .CRTr-* 6flSILJ
WELL TD VL
D' . se PT�IGp_.T. Rr.31L To. .o EL.L_ .. .
s • 40' 2Z
than 15 ft. from nearest trench . . . . . .
lI ' '1
FIPT,D CHPCK LIST.
Insp.by:
I
INITIAL SITP INSPFCTIOi; T )
Yes-
DIo
= .Conmonts
Property lines or corners found . . . . .
Can estimate house location . . . . . . . .
P
Am _
O
Will. driveway need cut . . . . .
Must trees be removed -hote these
NON FW W
Is deep hole representative of entire SD:, area
Additional doep holes needed. . . . . . , p .
Sufficient SITS area available considering
driveway cut, house location, separation
distances, etc.
41a, IAELL�SEPTICS -
-�
-_
•PVv ;Ci'
,
✓ .
DEPP HOLE DATA
ail. -� �'b'
Depth: # - - --
Water elevation:. _
Rock elevation:
• Soils degcr.lr_)tion-
'
te: _
FINAL SITE I'SPECTIOD? IIns . by:
'c
House located where shoran on approved plan
---
—
SDS located where approved . . , . . , .
_..._
1k,ng'th of trench moasured
Width of trench average
Slope of tile line and tr— encFi.acceptable .
Room allowed for expansion trenches . . . . .
Over'55e-ft. from swamp,vatercourse
_..
_•.
Natural soil not-.stripped or SDS area
unnecessarily graded . . . . .
10 Ft. rfaintained from prop.line and
20 £t. from house . . . .
Separation of trench from house, well
etc.- follows plan . – , - - --
. . . .
- • -
Nwnber of bedrooms checks . . . . .
Stones, brush, •stumps, rubble, etc: greater
than 15 ft. from nearest trench . . . . . .
'+
15 I't. of peripheral soil horizontally from
trench
�-
Junction boxes properly set
Coiild surface run off from driveway, roads,
ground surface, etc. channel near SDS ..
area. . . . . . .
Does lot dra ina ;e arn�evr 0. K. �i.n area of SD.S
a
FINAL GRADING OF SITE ACCEPTAME
�S�
L
J
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
_ ......
_' AF•F`IDAVi l - COkP0ECt1TE"- OWYER�= Af�ALT�,ATION .._� .+ :>~:q , °.. '� <�.�- -
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
Ve yk_
I , e3- lie Grit- j
represent that I am an officer or employee of the corporation and am authorized
o- jj
to act for
,.) r-0 J_ , "ie 1. �y'..S 6G",� ,`v✓l. G-,, V_ "-,) -
(Name of Corporation)
having offices at
Whose officers are:
President: tf�i
Vice - President:
- Secretary:
Treasurer:
(Name and Address
(Name and Address)
(Name and'-Addiess
(Name and Address)
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts relating
thereto.
Sworn to before me this 4.2 day Signed:`"'
of 19 it S Title:
a a
b-
1
Notary Public
Felicia G. yilinogradoff
(Votary Public
State of New York
# 4802507
Qualified in Putnam r -:. t,- v
Term Expires MF-rei ;o i 104. Corporate Seal
8/84
J
i
Y
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH.SERVICES
,Y
Date
Re:. Property of,n
Located at
414/41VSection 1'7V Block Lot 3 G
J _ h
Subdivision of
Subdv. Lot #LS Filed Map # Date
Gentlemen:
This letter is to authorizes -C,� /1 ,� // ✓��
a duly licensed professional engineer � or registered architect
(Indicate
to apply for a Construction Permit for a. separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and. to. supery .se_tie.Constructi,on.,of, said.
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
` o � Signed
Owner of Property
Countersi j
Ilk. a
P.E., Rsi1s# Address
Ire
Address
%2 y>
Telephone
Town
Telephone ` ' ; i '~L, "; }
)DEPT. OF
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_.OFFICE BUILDING.,- CARMEL, N: —Y 105d2--
DESIGN DATA /SHEET-SEPARATE SEWAGE DISPOSAL ,SYSTEM FILE /NO.
Owner �,/�f�:��%�'- Cola Address
Located at (Street / /�+la^� �i"c�k Sec.JZ,e, Block Lot
Indicate nearest cross street)
Muni Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
5
5
1
3 t
DEP-r. OF
T `
Notes: 1) T6 is to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
12) Depth measurements to be made from top of hole.
Role
Number CLOCK TIME'
PERCOLATION
PERCOLATION
Eun Elapse
No. Time
Start -Stop Min.
Depth to Water
From Ground Surface
Start Stop
Inches Inches
Water LFveI
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
5
5
1
3 t
DEP-r. OF
T `
Notes: 1) T6 is to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
12) Depth measurements to be made from top of hole.
DEPTH
G.L.
61'
1211
1811
2411
3011
36"
42tr.
4811
5411
6011
66t1
V11
78811
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION..OE_SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. r HOLE NO. -- HOLE N0:
yy 1 9
84"
INDICATE DIET, AT WHICH GROUND WATER .IS ENCOUNTERED
-� IN DIL WATER LEVEL RISES.'AFTER. EE-ING,t ENCOUNTERED; .
TESTS MADE BY i) i �✓� Date 3/- t::_
DESIGN
Soil Rate Used Nin/1 "Drop: S. D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity Gals. Type���
Absorption Area L.F. x24" width trench.
Other
name fir,, bi.gnature
Addre s s F SEAL
1 `T •p. �S
THIS SPACE FOR DEPARTMENT ONLY:
K S. , Soil Rate Approved Sq. Ft /Gal. Checked by Date
-Thi:3 is to CLT— If), Y t
-nnt.-trixted. as p.� tar -nd t?Lat the rys
z
.-zs t
---'ad ovez
w a s r!-nn u r.
' 4 T
s and r e C u..-, at o: 0 -f t 7�,: j;-, 1 y D e. D a r t-, e n t 0 f
Health and the ',Iew `or-k ,_" ate n t of Hc lalth.
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120(vp 11V,7
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Putna--, Gc,unty Department of Heajt".
Division of Enviro-mental P.e,-I-lh Service@
App Ved asnctcr for confo.;,,.a:-.ce wl'--a
p icab-, e T.-1 -73 I�e,,-ulati Orl.- ol tr
Pu am ount- i -alt'.'
Sure Title Date
P4
2
23
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27
37
37
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120(vp 11V,7
:5 ef,4'- 4,7�
Putna--, Gc,unty Department of Heajt".
Division of Enviro-mental P.e,-I-lh Service@
App Ved asnctcr for confo.;,,.a:-.ce wl'--a
p icab-, e T.-1 -73 I�e,,-ulati Orl.- ol tr
Pu am ount- i -alt'.'
Sure Title Date